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ST. CLOUD STATE UNIVERSITY UNCLASSIFIED PERSONNEL APPLICATION FORM (Saint Cloud State University)

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ST. CLOUD STATE UNIVERSITY
UNCLASSIFIED PERSONNEL APPLICATION FORM
Data requested in this application form will be used in evaluating your qualifications for the position for which you
have applied at St. Cloud State University, and, if you are selected, for subsequent promotion and tenure decisions. In
addition, the data may be used in the compilation of summary data required for local or system studies and reporting
requirements of state and federal agencies. Furthermore, this data may be shown to accrediting agencies, and to consult-
ants hired by the university or the State University System to evaluate programs and/or departments. Finally, selected data
may be released on the request of authorized university officials or state and federal agencies.
Complete each item as thoroughly and accurately as possible. Please note that the omission of requested data may
make it impossible for St. Cloud State University to give full consideration to your application.
I. Personal Data
Name________________________________________________________ Social Security Number ______________________________
Current Address ____________________________________________________________________________________________________
Street City State Zip Code County
Residence Phone _________________________________________ Office Phone ___________________________________________
Area Code Number Area Code Number
I. Educational Background
A. College Degree Data (Report all earned degrees, using an extra sheet if necessary.)
Data Item First Degree Second Degree Third Degree
Institution. . . . . . . . . . . . ___________________________ ___________________________ __________________________
City and State . . . . . . . . . ___________________________ ___________________________ __________________________
Degree . . . . . . . . . . . . . . ___________________________ ___________________________ __________________________
Date Rec’s. (Mo./Yr.). . . . ___________________________ ___________________________ __________________________
First Major . . . . . . . . . . . ___________________________ ___________________________ __________________________
Area of Interest . . . . . . . ___________________________ ___________________________ __________________________
Second Major . . . . . . . . . ___________________________ ___________________________ __________________________
Area of Interest . . . . . . . ___________________________ ___________________________ __________________________
Minor(s) . . . . . . . . . . . . . ___________________________ ___________________________ __________________________
B. Foreign Language C. Computer Languages
Language
Read Write Speak ______________________________
__________________________________ __________ __________ __________ ______________________________
__________________________________ __________ __________ __________ ______________________________
__________________________________ __________ __________ __________ ______________________________
D. Graduate Study (Provide information in SEMESTER HOURS
)
Total number of graduate SEMESTER HOURS
you earned toward your highest completed degree __________________________
Total number of graduate SEMESTER HOURS
beyond your highest completed degree ____________________________________
Date you last completed a course in your field of specialization for graduate credit _____________________________________
Month Year
Last First Middle
E. Doctoral Candidate
Do you have active status in a doctoral program? _______ Yes _______ No
If yes, please complete the following:
Institution___________________________________________________ City ______________________________ State __________
Date degree expected ________________________________________
Month Year
Have you completed all requirements except dissertation? ________ Yes _______ No
If yes, when were course requirements completed____________________________________________________________________
F. Future Educational Plans _______________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
III. Overseas Experience (Include service in the Military, Peace Corps, USO, or Red Cross and residence abroad for
study, work, educational travel, etc. Describe in detail the nature of the experience. Include information concerning
specific geographic area, dates and other pertinent facts.Attach an additional sheet if needed.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
IV. Professional Data
A. Scholarships and Fellowships____________________________________________________________________________________
_______________________________________________________________________________________________________________
B. Publications (Provide full bibliographic information. Attach an additional sheet if needed.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
C. Organizational Membership (Include names of all scholarly and professional organizations, listing any offices held.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
V. Personal Preferences in Teaching Assignments (If you are applying for a teaching position, list the courses you
are most interested in teaching and those you feel best prepared to teach. Asterisk those courses you have taught.)
Most Inter
ested Best Prepared
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
VI. References (List the names and addresses of at least three individuals who are in a position to provide recent first-hand
information concerning your demonstrated or potential qualifications for the position for which you are applying.)
Name
Address
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
______________________________________________ _________________________________________________
VII. Miscellaneous (Supply any additional information you may wish to provide that you feel will enhance your
chances of employment and facilitate consideration of your candidacy within the framework of the Equal
Opportunity/Affirmative Action Program.) ________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
VIII. Detailed Employment Record (Provide all applicable information on each academic and non-academic position
held, including full information on both full-time and part-time positions. List present position first and work back-
wards.)
1. Institution or Firm _________________________________________ City____________________________ State ______________
Your exact position title _________________________________________________________________________________________
If position was in higher education: Your rank ___________________________ Tenured: _____ Yes ______ No
Name and address of immediate supervisor________________________________________________________________________
______________________________________________________________________________________________________________
Dates of Employment: From____________________________ To ____________________________________
Month Year Month Year
(Full-time) ________ (Part-time) __________ If part-time, indicate percent of time involved: __________________________
Specific duties and responsibilities:________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Institution or Firm _________________________________________ City____________________________ State ______________
Your exact position title _________________________________________________________________________________________
If position was in higher education: Your rank ___________________________ Tenured: _____ Yes ______ No
Name and address of immediate supervisor________________________________________________________________________
______________________________________________________________________________________________________________
Dates of Employment: From____________________________ To ____________________________________
Month Year Month Year
(Full-time) ________ (Part-time) __________ If part-time, indicate percent of time involved: __________________________
Specific duties and responsibilities:________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3. Institution or Firm _________________________________________ City____________________________ State ______________
Your exact position title _________________________________________________________________________________________
If position was in higher education: Your rank ___________________________ Tenured: _____ Yes ______ No
Name and address of immediate supervisor________________________________________________________________________
______________________________________________________________________________________________________________
Dates of Employment: From____________________________ To ____________________________________
Month Year Month Year
(Full-time) ________ (Part-time) __________ If part-time, indicate percent of time involved: __________________________
Specific duties and responsibilities:________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
4. Institution or Firm _________________________________________ City____________________________ State ______________
Your exact position title _________________________________________________________________________________________
If position was in higher education: Your rank ___________________________ Tenured: _____ Yes ______ No
Name and address of immediate supervisor________________________________________________________________________
______________________________________________________________________________________________________________
Dates of Employment: From____________________________ To ____________________________________
Month Year Month Year
(Full-time) ________ (Part-time) __________ If part-time, indicate percent of time involved: __________________________
Specific duties and responsibilities:________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
5. Institution or Firm _________________________________________ City____________________________ State ______________
Your exact position title _________________________________________________________________________________________
If position was in higher education: Your rank ___________________________ Tenured: _____ Yes ______ No
Name and address of immediate supervisor________________________________________________________________________
______________________________________________________________________________________________________________
Dates of Employment: From____________________________ To ____________________________________
Month Year Month Year
(Full-time) ________ (Part-time) __________ If part-time, indicate percent of time involved: __________________________
Specific duties and responsibilities:________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
How did you learn of the vacant position for which you are applying: ______________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
IMPORTANT
The state has the right to verify information provided in the application. False information may subject an applicant to the
penalty provisions of M.S. 43A.39. In connection with this application for employment, I authorize the state of Minnesota
and any agent acting on its behalf to conduct an inquiry into any job-related information contained in this application,
including, but not limited to, my records maintained by an educational institution relating to academic performance such
as transcripts. Moreover, I hereby release the State of Minnesota and any agent acting on its behalf from any and all liabili-
ty of whatsoever nature by reason of requesting such information form any person.
I declare that all information provided is true and complete and acknowledge that I have read and understand the
information above.
Date: Signature (do not print):
TTY: 1-800-627-3529 SCSU is an affirmative action/equal opportunity educator and employer.
This material can be made available in an alternative format. Contact the sponsoring department.
PS337
Revised 1/02
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ST. CLOUD STATE UNIVERSITY UNCLASSIFIED PERSONNEL APPLICATION FORM (Saint Cloud State University)

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Completed 25 August 2020

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